Treatment approach37

At present it appears that all the subtypes of delusional disorder are potentially responsive to treatment. If treatment fails, consider patient non-compliance first before abandoning the current approach.

The best-attested treatment results refer to the somatic subtype, with smaller literatures on the erotomanic, jealousy, and persecutory subtypes, and virtually nothing on the grandiose form. A wide variety of neuroleptics has been reported upon, but at present pimozide, a diphenylbutylpiperidine neuroleptic, is the drug of first choice.(l°4) Antidepressants and benzodiazepines are usually ineffective as first-line treatments and monoamine oxidase inhibitor antidepressants are contraindicated as they may worsen the delusions. There is no literature on the use of newer atypical neuroleptics in delusional disorder, but this should certainly be an area of study in the future.

Currently the best estimate of treatment outcomes, admittedly from a very scattered literature, is that, if the diagnosis is correct, the patient compliant, and the treatment adequate, recovery (defined as 'return to full function with total or near-remission of symptoms') occurs in approximately 50 per cent of all patients, no matter which neuroleptic has been used. A further 30 per cent will show substantial but less complete improvement. If pimozide has been the specific neuroleptic the results are a little better and nearly 90 per cent of all patients are reported to be recovered or improved. An unknown proportion of the remainder have failed to improve because they have not taken the medication adequately. Although based on mostly non-blind trials these figures come from a worldwide literature which does show marked consistency in reports of recovery rates.

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